Focused utilization review strategies

Area of Science:

• Health Services Research
• Healthcare Management
• Quality Improvement

Background:

• Nonacute inpatient hospital admissions represent a significant area for utilization review (UR) and cost-saving opportunities.
• Existing UR strategies may not be optimally efficient in identifying these nonacute cases.
• The Michigan Health Care Education and Research Foundation investigated methods to enhance UR effectiveness.

Purpose of the Study:

• To compare three focused utilization review strategies for identifying nonacute inpatient hospital admissions.
• To determine the most effective and efficient method for detecting nonacute cases.
• To assess the potential for efficiency gains through targeted UR.

Main Methods:

• Utilized Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria to identify nonacute admissions.
• Analyzed 8,973 cases across 73 Michigan hospitals.
• Compared focused UR strategies, including those using concentration ratios and targeting specific Diagnosis-Related Groups (DRGs).

Main Results:

• Nonacute admissions were prevalent in medical, psychiatric, and substance abuse cases, with lower rates in surgical cases.
• Strategies employing concentration ratios were most indicative of potential efficiency gains.
• Focusing UR on DRGs with >15% nonacute rates captured 41% of admissions and accounted for 85% of nonacute admissions, 85% of nonacute days, and 80% of potential dollar savings.

Conclusions:

• Targeted utilization review, particularly focusing on DRGs with high nonacute admission rates, is an effective strategy.
• This focused approach significantly enhances the efficiency and effectiveness of the overall UR process.
• Healthcare organizations can achieve substantial cost savings by prioritizing UR efforts on high-risk DRGs.